(CONFIDENTIAL) ATTACHMENT JV-2020
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar Number and Address):
TELEPHONE NUMBER:
FOR COURT USE ONLY
To keep other people from
seeing what you have
entered, please press the
Reset Form button at the end
of this form when finished.
FAX NUMBER (Optional):
EMAIL ADDRESS (Optional):
ATTORNEY FOR (Name):
SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CLARA
COURT ADDRESS:
201 North First Street, San José, CA 95113
MAILING ADDRESS:
191 North First Street
CITY AND ZIP CODE:
San José, CA 95113
BRANCH NAME:
Juvenile Dependency
CHILDREN’S NAMES:
Hearing
Date→
CASE NUMBER:
FINANCIAL DECLARATION
Financial Evaluation Hearing Date:
RELATED CASES:
Time:
Dept.
THIS SECTION FOR COURT USE ONLY
SUBSEQUENT FINANCIAL DECLARATION
I am Requesting a Hearing for Reconsideration of my Order to Repay
Attorney Fees filed on (date):
My Request is Based on:
Change of Financial Circumstances
Financial Inability to Comply with Reunification Plan Requirements
Hearing
Date→
Reconsideration Hearing Date:
Time:
Dept.
1. Personal Information:
Name:
Social Security Number:
Other Names Used:
I.D. or Driver’s License:
Address:
Check here if you are In custody. Detention Center:
Release Date:
City:
Zip Code:
Date of Birth:
2.
I receive (check all that apply):
Medi-Cal
IHSS (In-Home Supportive Services)
Phone:
SNAP
Age:
Alternate Phone:
SSI
SSP
County/Relief/General Assistance
CalWORKS or Tribal TANF (Tribal Temporary Assistance to Needy Families)
CAPI (Case Assistance Program for Aged, Blind and Disabled)
3.
My gross monthly income (before deductions for taxes) is less than the amount listed below:
If you checked box 3, circle the Family Income section that applies to your case.
Family Size
Family Income
Family Size
Family Income
Family Size
Family Income
1
$1,228.05
3
$2,092.71
5
$2,959.38
2
$1,659.38
4
$2,526.05
6
$3,392.71
If more than 6
people in family,
add $433.34 for
each extra person.
If you checked any boxes in section 2 or 3 above, skip sections 4 through 8. Go to section 9, read and fill in the section
and sign the form.
JV-2020 REV 01/01/16
FINANCIAL DECLARATION / SUBSEQUENT FINANCIAL DECLARATION
Page 1 of 4
(CONFIDENTIAL) ATTACHMENT JV-2020
CHILDREN’S NAMES:
CASE NUMBER:
RESPONSIBLE PARTY’S NAME:
RELATED NUMBERS:
4.
5.
Family:
a. Marital Status:
Single
Married
Divorced
Separated
Widowed
b.
Name of Spouse/Partner:
c.
Number of Dependent Children Living with You Who are Under the Age of 18:
d.
Dependents’ Names and Ages:
Domestic Partner
Employment:
Your Employment
Spouse/Partner Employment
If you checked “Married” or “Domestic Partner” in 4a,
above, fill out this section.
Employer:
Employer:
Address:
Address:
City and Zip Code:
How Long
Employed?
Phone:
Working
Now?
Monthly Salary:
City and Zip Code:
Take Home Pay:
How Long
Employed?
Phone:
Working
Now?
Monthly Salary:
If not now employed, who was your last employer?
(Name, Address and Zip Code)
If not now employed, who was your last employer?
(Name, Address and Zip Code)
Phone number of last employer:
Phone number of last employer:
6.
Take Home Pay:
Income and Assets:
Other Income
What do you own?
Unemployment and Disability .................. $
Cash
Social Security/ /SSD............................... $
Real Property/Equity ................................$
General Relief.......................................... $
Cars and Other Vehicles ..........................$
Worker’s Compensation........................... $
Life Insurance...........................................$
Child Support Payments .......................... $
Bank Accounts (list below) .......................$
Foster Care.............................................. $
Stocks and Bonds ....................................$
Other Income ........................................... $
Total
$
...................................................$
Business Interest......................................$
0
Other Assets.............................................$
Total
$
0
Name and Branch of Bank:
Account Numbers:
JV-2020 REV 01/01/16
FINANCIAL DECLARATION / SUBSEQUENT FINANCIAL DECLARATION
Page 2 of 4
(CONFIDENTIAL) ATTACHMENT JV-2020
CHILDREN’S NAMES:
CASE NUMBER:
RESPONSIBLE PARTY’S NAME:
RELATED NUMBERS:
7.
Expenses
List your monthly expenses
Monthly cost of services required by your
reunification plan
Rent or Mortgage Payment...................... $
(If you do not know the cost, please indicate “UK” )
Car Payment............................................ $
Parenting Classes …… ......................... $
Gas and Car Insurance............................ $
Substance Abuse Trmt .......................... $
Public Transportation ............................... $
Therapy/Counseling ………………….… $_______________
Utilities (Gas, Electric, Phone, Water)...... $
Medical Care/Medications ........................$
Food....................................................... $
Domestic Violence Counseling.................$
Clothing and Laundry............................... $
Batterers’ Intervention ............................ $
Child Care................................................ $
Victim Support ..........................................$
Child Support Payments ........................ $
Regional Center Programs .......................$
Medical Expenses.................................... $
Transportation ........................................ $
Other Necessary Monthly Expenses........ $
In-Home Services.....................................$
Total
$
0
Other ........................................................$
Other ........................................................$
Total
8.
0
$
Loan/Expense Payments
Name of lender and type of loan/expense
JV-2020 REV 01/01/16
Monthly Payment
Balance Owed
$
$
$
$
$
$
FINANCIAL DECLARATION / SUBSEQUENT FINANCIAL DECLARATION
Page 3 of 4
(CONFIDENTIAL) ATTACHMENT JV-2020
CHILDREN’S NAMES:
CASE NUMBER:
RESPONSIBLE PARTY’S NAME:
RELATED NUMBERS:
9.
I,
, understand that a hearing will be set to determine my ability to pay the
costs for legal services. If I do not appear at the hearing and do not pay in full the assessed costs for legal services, the court
may enter a judgment against me without further notice or order.
I understand that I have a right to a separate evidentiary hearing to determine my ability to pay the assessed fees, in the
event that I dispute the judicial officer’s order for repayment. I further understand that I am entitled to the following at that
evidentiary hearing:
•
•
•
•
•
•
The opportunity to be heard in person;
The opportunity to present witnesses and written evidence;
The opportunity to confront and cross-examine witnesses brought against me.
Disclosure of the evidence against me;
A written statement of findings of the court;
To be represented by an attorney and, if I cannot afford an attorney, to have an attorney appointed to represent me; and
I understand that at any time prior to full repayment of any fees ordered by the court that I may petition the court to modify or
vacate its previous judgment on the grounds of a change in circumstances with regard to my ability to pay the judgment.
I certify under penalty of perjury that the above information is true and correct. I understand that perjury is punishable by
imprisonment; I also consent to the release of my credit information from credit reporting agencies.
Date:
X
(TYPE OR PRINT NAME OF RESPONSIBLE PARTY/APPLICANT)
(SIGNATURE OF RESPONSIBLE PARTY/APPLICANT)
Clerk’s Certificate of Service
personal service
I certify that I am not involved in this case. This notice of hearing was served on the responsible party by
mail and to counsel for the responsible party by
mail
pony mail at the street address listed above.
Date:
Clerk, By
, Deputy
FOR COURT USE ONLY
TOTAL INCOME
$
FEES BASED ON UNIFORM COST MODEL
$
TOTAL EXPENSES
$
TOTAL FEES ASSESSED
$
NET DISPOSABLE INCOME
$
PAYMENT DUE TO COURT ON
Reset Form
JV-2020 REV 01/01/16
FINANCIAL DECLARATION / SUBSEQUENT FINANCIAL DECLARATION
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